Israeli Surgeons Helping Swaziland in Drive to Curb HIV

By Craig Timberg
Washington Post Foreign Service
Sunday, October 21, 2007

MBABANE, Swaziland -- The young men seated in a cramped waiting room in Swaziland's capital twitched with nerves. Feet tapped. Fingers drummed. The occasional brave joke was delivered with a smirk.

Beyond a wooden door a few feet away, two Israeli doctors donned blue hospital scrubs adorned with faded Hebrew script. Stepping into a modest room where only a dangling sheet separated the operating tables, they prepared to perform the world's oldest surgery.

So began Day 10 of an uncommon experiment in international assistance. Small teams of Israeli surgeons have begun circumcising Swazi men, deploying an ancient ritual in hopes of curbing the terrible modern malady of AIDS.

A series of studies have shown that circumcised men are at least 60 percent less likely to contract HIV. Far less clear is how meager public health systems already overwhelmed by the AIDS epidemic can offer the procedure widely enough to slow the epidemic's ruinous spread.

"For us the major constraint is surgeons, doctors," said Dudu P. Simelane, executive director of the Family Life Association of Swaziland, a nongovernmental group hosting the Israelis.

Medical experts in Swaziland, which has fewer than 100 doctors and the world's highest rate of HIV infection, say that over the next five years, they would like to offer the procedure to all 200,000 of this tiny southern African nation's sexually active men, at a rate of roughly 200 a day. That's 20 times faster than the current pace in this country of 1.1 million.

No country has ever attempted anything like it -- save for Israel, whose doctors circumcised 80,000 men after the fall of the Berlin Wall in 1989 brought a flood of new immigrants, mostly adults who had grown up in Soviet bloc countries that prohibited Jewish rituals.

The value of circumcision remains hotly debated in many countries, including the United States. Some activists regard it as a form of genital mutilation with no redeeming medical benefit. In African countries that have traditions of ritual circumcision, unsterile conditions and poor training sometimes cause serious complications, including the mutilation and even death of adolescent boys.

But scientists say that the foreskin has cells unusually receptive to the AIDS virus and that removing it causes the penis head to grow thicker and more resistant to sexually transmitted infections. The World Health Organization said in March that making circumcision widely available, inexpensive and safe could prevent 5.7 million HIV infections over the next 20 years.

Swazis, like several southern African ethnic groups, have abandoned their own traditional circumcision rituals, but widespread publicity of recent studies has spurred renewed interest in the procedure, in modern medical facilities.

The men waiting for the free circumcisions Friday morning said that they had friends or relatives who already had been circumcised and that, based on their advice, they wanted the easier hygiene and HIV protection offered by the procedure. One said his girlfriend had urged him to do it.

Africa Sihlongonyane, 26, said his father died of AIDS in 2004, wasting away over several months. When a friend was circumcised by the Israeli doctors last Monday, Sihlongonyane decided to do the same.

Minutes before being injected with local anesthesia, he said: "I've been told it's not painful. Even if it is painful, it won't stay."

Six Israeli doctors are slated for two-week stints this year under the program, organized by the Jerusalem AIDS Project and underwritten by Hadassah, a U.S.-based Jewish organization, and other donors.

One of the first to arrive was Melvyn Westreich, a jovial, portly plastic surgeon who retains the accent of his native Bronx neighborhood despite three decades of living in Israel. He helped organize the mass circumcision campaigns there in the 1990s and now oversees the country's mohels, religious men who circumcise baby boys in bris ceremonies, typically on their eighth day of life.

The surgery for adult men is more complicated, with a greater possibility of heavy bleeding and other problems. Men typically heal in a few days, and they are supposed to abstain from sex for several weeks while the wound closes completely. Resuming intercourse too quickly may make them temporarily more vulnerable to HIV, scientists say.

In Swaziland, Westreich has focused on improving the flow of patients through the clinic. Saving even a few minutes with a new stitching technique, or injecting the men with anesthesia in a waiting area rather than in the busy operating room, means more circumcisions can be done each day, each week, each month.

"The trick is to get the most done with the personnel available," he said.

The mission has not gone entirely smoothly. The Israeli doctors expected mainly to train Swazi doctors how to circumcise adults, they said. But many Swazi doctors already know how to perform the surgery. What they need most of all, they have told the Israelis, are extra hands to help get enough done to impact the epidemic.

The beleaguered Swazi health system routinely runs low on such basics as sutures, gloves, dressings and surgical tools. To control bleeding, the Israeli doctors brought along a cauterizing machine not available in Swaziland.

Yet in a series of occasional "Circumcision Saturday" events, the Swazi surgeons have shown that they can each do 10 of the procedures -- which take about 25 minutes -- per day.

If that speed could be maintained every weekday, medical experts here say, it would take just four doctors at each of five separate facilities to reach the target of 1,000 circumcisions a week.

The demand for circumcision -- especially surgeries that are free or subsidized -- appears to far outstrip supply in Swaziland. At one Circumcision Saturday, a crowd of men grew unruly after it became clear that the doctors could perform subsidized circumcisions on only about half of them; the crowd later dispersed after being given vouchers for other dates.

The men in the waiting room Friday morning said they knew others who wanted the procedure. Some of the patients planned to give reports to friends and brothers after it was over.

As Westreich finished one procedure, he asked Cilongo Fakudze, 28, an unemployed taxi driver, "How was it?"

With the anesthesia still working, Fakudze replied, "It was not that bad."

Then Fakudze gingerly climbed off the operating table, lowered his maroon hospital gown and walked slowly -- with delicate, bowlegged steps -- to a recovery room.